Learning leadership in diabetes
self-care

Campamento
Diabetes Safari, México

Interview with Dr. Stan De Loach by Diabetes
Health Magazine

February 2010

Dr. Stan De Loach is a bicultural,
trilingual Certified Diabetes Educator (one of the first 13 diabetes educators
ever certified in Mexico) and clinical psychologist, not to mention a pianist,
composer, and writer. Born and educated in the U.S., he has been
a resident of Mexico for decades, and his first love is the annual bilingual
diabetes camp for children and adolescents that he co-founded, the four-day
Campamento Diabetes Safari.

His journey to the camp began
41 years ago, when he developed type 1 diabetes at the age of 21, an age
when many find it especially hard to accept. He didn’t find it so,
however, primarily because the dietary advice at the time was so liberal
with carbs that he didn’t have to change his diet at all. “When you’re
told that you should eat large portions of fruit, bread, cereal, and milk,”
he says, “it isn’t difficult to adjust because you’ve been eating that
way all along.” It was frustrating, however, because “whatever adaptations
you made, there were no apparent or quantifiable results to show for it.
There were no portable blood glucose meters yet.”

Dr. De Loach found his way to
stable glycemic control partly on his own, through experience at an expensive
upscale buffet in Chicago in the 1980’s. He recalls, “There was a
fancy hotel with an all-you-can-eat Sunday afternoon buffet. I decided
that it would be ridiculous to go there to eat their mashed potatoes or
bread because those foods are cheap and I could get them at home.
So I would stuff myself on the crab, shrimp, prime rib, asparagus spears
with butter, Caesar salad, and salmon, and then on the walk home I would
be hypoglycemic. And I thought, ‘Something is weird here because
I ate like a pig, yet my sugar is low.’ Little by little, it dawned
on me that it was the carbs that were causing the high blood sugars, not
the proteins or fats or vegetables. At that point, I began to modify
my diet in an attempt at normoglycemia.”

Years later, he discovered Dr.
Richard Bernstein’s book The Diabetes Solution, which clarified
the influence of carbs in the management of diabetic hyperglycemia “and
was specific in terms of quantities. Dr. Bernstein’s precision, based
on learning from his own experience, really changed my life and my blood
glucose control. He is a guide, a thinker who can provoke you to
think and to learn, who uses real data and research rather than just theory
or what experts who often may not have diabetes are saying. He presents
his reasoning, and then you analyze it yourself. Just because a professional
organization says to eat 50-60% of your diet in carbs doesn’t mean that
it’s valid. Eat that way and check blood glucose levels; then eat
Dr. Bernstein’s way and check. You have your measurements to go by,
so you can know the ‘real’ results in your unique body. The positive
difference is convincing.

“Explain to me,” Dr. De Loach
asks, “how a balanced diet can consist of 50-60% carbs, 20% protein, and
20% fat. How is that ‘balanced’? With these proportions, the
commonly promoted balanced diet is really not balanced at all. A
Spanish colleague argues that what we want to promote in diabetes care
is an unbalanced diet in order to produce glycemic balance.” “No
one dies of diabetes,” notes Dr. De Loach. “We die of chronic diabetic
hyperglycemia and its effects, the diabetic complications, which can be
disabling and fatal. Manage hyperglycemia, not diabetes. Hyperglycemia
is manageable; it’s what you can effectively ‘control.’”

That Dr. Bernstein’s ideas are
controversial “is totally perplexing,” says Dr. De Loach, “because, as
I tell my clients, with any treatment that you are prescribed, how are
you going to measure its success or suitability? In the case of type
1 diabetes, you can gauge it by your blood sugars. If you’re heading
toward 200 mg/dL, you can then decide whether the specified insulin doses,
the food regimen, the activity level are providing effective treatment?
Dr. Bernstein may be controversial in some quarters, but rarely among those
who have tried his methods. Many people, however, are unwilling to
try them.”

Dr. De Loach believes that one
deterrent to trying low-carb methods of glycemic control lies in the lack
of scrutiny given to statements and assertions from prestigious professional
organizations. You see these declarations, ‘Oh, a high percentage
of carbs is good, even necessary, for a person with diabetes.’ There’s
no proven basis for believing that’s true, but when you hear the message
repeatedly, to change or do something different is going to cause anxiety
because you think ‘I’m doing the wrong thing, and I’m going to kill myself
by not eating so many carbs.’ That’s when the trusty blood glucose
monitor can restore reason and orientation.”

Dr. De Loach is a convincing proponent
of not relying on conventional wisdom when it comes to your own diabetes
management. “If people who have diabetes think of themselves as passive
recipients of infallible medical wisdom, sometimes imparted by professionals
who do not even have diabetes, they’re not going to get optimal care.
I can’t tell anyone exactly how much insulin they need, for example.
But you, by experience and measurement of your blood sugars, can learn
that. To be passive in your health-care relationship is just not
to your advantage. Basically, the responsibility lies with the person
affected by diabetes to learn to handle multiple decisions, during every
24-hour day.

"If a client with diabetes goes
blind, how will that affect me? Maybe emotionally, but it’s going
to affect that person quite a lot, physically, economically, and emotionally.
The person who has the authority and responsibility for managing diabetic
hyperglycemia is the person who has it.”

“Glycemic control for the person
with diabetes is complicated by the medicine that we all use daily in multiple
doses and in great quantity: food. It is a medicine that requires
more medicine (insulin) and that no one can dose except the individual
with diabetes. It has emotional significance that other over-the-counter
medicines do not have, and it exerts rapid and powerful physiological effects.
Eating 200 grams of carbohydrate quickly affects blood glucose, so it’s
a potent medicine with psychological and social meanings. Food certainly
complicates the life of any person with diabetes.”

The conviction that each individual
holds the authority and responsibility for managing glycemic levels guides
the way Campamento Diabetes Safari is organized. “Who is capable of managing
hyperglycemia? It’s really the Campers, to whom we say the first
day, ‘You’re not slaves here. It’s not a question of obedience, because
you’re young and we’re older. You have diabetes. Who’s going
to be in charge of managing your blood sugar for the rest of your life?
It’s you! It would be nice if daddy could do it, it’d be nice if
I could, but we can’t. You can, however. What you choose to
learn here may help in your efforts.’”

“They promptly comprehend this
message, which is followed by the disclosure that there is no battle, no
external force involved. We don’t tell them to check their blood
sugar. We don’t order them to ‘not eat that.’ Studies show
that when young persons with diabetes, or adults for that matter, have
free access to the tools they need to manage their blood glucose, they
generally choose to do so. The Campers have their own meter and unlimited
strips, thanks to Abbott Laboratories de México. They carry
and use them at their discretion.

“Guidelines often recommend checking
blood sugars four times a day if you’re using insulin. We don’t recommend
four or 12 times a day. It’s whatever you judge prudent, the parameter
suggested being that you do it whenever you don’t know. If you know
your blood sugar level, fine, you’ll know what to do. If you don’t
know, it could be worthwhile checking.” Campers typically check blood
sugars an average of 11 times per day. The results of this self-directed
learning process are impressive. An article describing the Campers’
glycemic levels1
indicated that the mean blood glucose value was 209 mg/dl on arrival at
the camp and 87 mg/dl on departure. A normal blood glucose value
lies between 71 and 99 mg/dl.

“Campers also determine for themselves
how much ultrarrapid insulin analogue to take before meals. Staff
collaborates with them in articulating relevant learning from previous
experiences with bolus insulin doses. The meals are all buffets,
from which Campers choose whatever they like. They are remarkably
competent at calculating the dose of insulin needed to match their appetite.
They also choose to exercise or not, often related to their immediate glycemic
goals.”

“We wisely keep the educational
focus on glycemic goals. If the Campers cannot learn to manage hyperglycemia
in a diabetes camp where we have professionals with tons of experience
and knowledge, how will they learn at home, where that expertise may be
unavailable? If they choose to learn through the ready consultation
and shared interpretation of experience offered at camp, they could be
expected to engineer normal blood sugars most of the time, if they wish.
So theoretically, glycemic values could be normalized more easily at camp
than at home. Sixty percent of Diabetes Safari’s staff members have
type 1 diabetes. They are expected to maintain an A1c of less than
5.2%. By doing so, they demonstrate, model, and confirm the feasibility
of normal glucose values, at camp as well as at home.”

Dr. Elliot Joslin's timeless and
invaluable belief of 85 years ago, that education is not part of the treatment
of diabetes, but rather is the treatment itself, influences Campamento
Diabetes Safari, which is designed to be educational, not recreational.
“Campers do go swimming, play, and recreate, but all is turned to opportunities
for learning about what daily decisions and behaviors can mean in terms
of glycemic management and goals. Because education for type 1 diabetes
has to be individualized, you can’t give classes or just general information.

For that reason, the question
of the individual’s authority and responsibility is also brought into the
matter of diabetologic education. In some diabetes camps, there is
a cabin master or mistress who controls the number of strips, the test
times, the meters, and the food intake, so the Campers are not really in
charge of or responsible for the management of their own glycemia.
But at Diabetes Safari, it’s all on the Camper, who sets the curriculum
and asks for the support and consultation necessary for his or her self-directed
learning.”

As a clinical psychologist, Dr.
De Loach brings expertise in system dynamics to the camp’s design.
“We try to focus on the whole system, because all parts of a system interact
and their interactions increase or reduce the system's effectiveness.
The entire staff and all Campers meet twice a day in what are called plenary
sessions, each lasting about an hour. There is no assigned topic.
You can say whatever you want to say or nothing at all, about anything
going on in yourself or in the temporary social system that is the Campamento.
The meetings are opportunities for Campers to speak their mind, in a setting
where it’s permitted and respected but not forced. Their inner strengths,
weaknesses, and resources find voice at the plenary meetings, joining the
parts of the sytem together and focusing us on the beauty and pain of here-and-now
reality.”

The staff is available around-the-clock
to accompany Campers in their pursuit of whatever they need and wish to
learn. Whether or not to implement the ideas or strategies that result
from consulting with staff always remains the Camper’s decision and responsibility.
Dr. De Loach emphasizes the importance of the public nature of staff’s
self-care behaviors. “Those of us with diabetes check our blood sugars
and take insulins in public. The Campers observe our meter readings.
When they see staff who do not have type 1 diabetes check their postprandial
blood sugar, they think, ‘Okay, these bigwigs have been saying that a normal
blood glucose is 71 to 99 mg/dl, and this endocrinologist without diabetes
just got through eating and has 84 mg/dl, so maybe that really is a normal
blood sugar.’ They learn from the public nature of staff's and their
own behaviors.”

Dr. De Loach does not use a pump
or continuous glucose monitor, because he is satisfied with results using
injections of ultrarrapid and basal insulin analogues. “I ask myself
the same question that I ask my clients. How can you tell if the
treatment that you’re using works or is good enough? The answer in
my book is that if your blood glucose is between 71 and 99 mg/dl most or
all of the time (that is, an A1c of 5% or less), then that’s effective
treatment. If not, I would consider adjusting or modifying treatment.

"I haven't felt the need to use
a pump to normalize my blood glucose levels. In my experience, if
you can’t get your blood sugar stable in a near-normal range with injections
of insulins, you can’t do it with a pump either. It’s not a matter
of how you’re getting that insulin into you; it’s knowing how much and
what kind and at what time, and, of course, your food intake and activity
level. Some Campers are distressed when I say that glycemic
management is an adventure in applied mathematics, but I think it is true.”

The clinical psychologist in Dr.
De Loach comes to the fore when he discusses the feelings of depression
that persons with diabetes may experience when they find themselves unable
to manage their blood sugar levels, in spite of effort. He relates
the painful feelings to others’ (parents’, health care professionals’)
and their own easy acceptance of harmful hyperglycemia simply because after
all one has type 1 diabetes and so it’s expected or “natural.” “It’s
as if a person with diabetes had no right to have or expect to have a ‘normal’
blood glucose level,” he says. “Usually, the first treatment experience
for a person with type 1 diabetes is of failure. Because you will
be told to do thus and so, and you will do it, and you will still have
hyperglycemia or hypoglycemia most or all of the time. That experience
of failure has to be modified by the realization that you can actually
manage it. It is not rocket science, as Dr. Bernstein says, and you
can learn how to do it.

“Another source of pain for young
people with type 1 diabetes is the anguish that comes from the passage
of time after diagnosis, without knowing and without learning. Parents
and healthcare professionals are not always aware of the anguish that children
and adolescents feel when they experience abnormal blood sugars.
They feel profound anguish because they know that chronic hyperglycemia
is not normal or without negative consequence for them somewhere down the
road. But they may feel impotent or be uncertain of how to alter
the cause of their anxiety and dread.

"At camp, young people can learn
strategies that allow successful blood glucose management, which can alleviate
the anguish and depression. They learn through experience by making
food choices, figuring out insulin doses, having the courage to share and
subject to validation their reasoned convictions, and monitoring the glycemic
results. Their exercise of authority and responsibility is the only
real antidote to the anguish and depression. In the published study
mentioned previously, the Campers’ average 3-day blood glucose was 95 mg/dl.
That’s pretty darn normal. Staff didn’t prescribe their insulin doses
or decide what they ate. The Campers did. They made their choices,
and the results are theirs.”

NOTA:Campamento Diabetes
Safari is a nonprofit venture that charges only $230 (in 2011) per camper
because it is supported by private donations and corporate contributions
of supplies. To contribute or for registration details, see www.diabetes-safari.com.

For additional information on
Campamento Diabetes Safari, see the 2008 article from the website of Diabetes
Health magazine, “You
Can’t Push the River."